The Source for Neurovascular News and Education

March 29, 2024

 

In a retrospective study, treating patients at high risk for subsequent stroke resulted in high rates of early neurologic improvement.

 

Endovascular revascularization can be successfully performed in select patients at risk for neurological deterioration because of symptomatic nontandem internal carotid artery occlusion (ICAO), according to the results of a study published online April 29, 2018, in the Journal of NeuroInterventional Surgery.

Many patients who present with ICAO also have large vessel occlusions (LVO), together known as tandem occlusions.

“We know that when we go in a patient with tandem occlusion, the main reason to go in is to open the lesion in the brain, but when they have a tandem occlusion we know that it is easy to open up the occluded carotid artery as well,” Tudor G. Jovin, MD (University of Pittsburgh, PA), told Neurovascular Exchange. “If that is feasible, why not do it even when there is no tandem lesion in the brain?”

To examine that question, Jovin and colleagues conducted a retrospective cohort analysis of 107 patients who presented to their center between 2003 and 2016 with ischemic stroke and ICAO. The median admission NIH Stroke Scale was 8 and the median time from symptom onset to treatment was 25 hours.

Overall, successful revascularization was achieved in 92% of patients. Distal embolization was the most common procedural complication (22%), which required intra-arterial pharmacologic thrombolysis in 16% of cases. Distal embolization was associated with new or worsened radiographic stroke burden. Other procedural complications included intracranial vessel perforation and dissection of the petrous or cavernous ICA segment. Regression analysis failed to find any baseline characteristics that were significant predictors of successful revascularization. On the other hand, two factors were predictive of dramatic early improvement:  younger age and smaller infarct burden.

By discharge, 83% had stable or improved NIH Stroke Scale scores, and by 3 months, 65% of patients had achieved functional independence, defined as mRS 0-2. Among 65 patients who had long-term imaging follow up (to 18 months), ICA and stent patency was 92%.

Whom to Treat?

There is a gap in knowledge with regard to the endovascular management of patients with ICAO, according to Jovin. Among the small percentage of patients who have stroke because of ICAO, most reports refer to patients with tandem occlusion, who present with acute stroke symptoms.

However, there are also a number of patients that presented with only ICAO. Many of these patients are stable, but a subset will have hemodynamic impairment and a low-flow state in the brain, Jovin said.

“These are patients that are at high risk for subsequent strokes,” he said.

Although Jovin and colleagues have been treating patients with ICAO, including nontandem ICAO, for many years, questions remains about which patients are most appropriate for treatment. He noted that a combination of clinical criteria and imaging helps in patient selection.

“These patients tend to have mild neurological deficit that slowly gets worse, or fluctuating impairment with a trend towards worse,” Jovin said. “In parallel, we would also try to get imaging data to support hemodynamic impairment and to show that there is a perfusion deficit in the territory supplied by the internal carotid artery.”

Jovin also acknowledged that these procedures are clearly not as safe as regular carotid stent procedures.

“There is almost guaranteed thrombus at the site of the occlusion, and the patients we are dealing with often don’t have much in reserve to withstand the procedure … they don’t have good collaterals,” Jovin said, adding that the margin of error is small.

 


Sources:

Jadhav A, Panczykowski D, Jumaa M, et al. Angioplasty and stenting for symptomatic extracranial non-tandem internal carotid artery occlusion. J NeuroInterv Surg. 2018;Epub ahead of print.

 

Disclosures:

Jovin reports consulting for Neuravi, Codman Neurovascular, Stryker Neurovascular, and Fundacio Ictus; and owning stock in Anaconda, Silk Road, and Blockade Medical.